后外侧入路撬拨复位简单内固定治疗胫骨后外侧平台塌陷性骨折

Posterolateral minimal incision,poking reduction,and simple internal fixation in treatment of collapsed fractures of posterolateral tibial plateau

目的探讨经后外侧入路有限切开、撬拨复位、简单内固定治疗胫骨后外侧平台塌陷性骨折的临床效果。方法 2010年10月—2016年1月,采用后外侧入路、撬拨复位、克氏针或螺钉等简单内固定治疗16例胫骨后外侧平台塌陷性骨折患者。男10例,女6例;年龄22~63岁,平均43.5岁。致伤原因:跌伤5例,交通事故伤7例,高处坠落伤4例。均为闭合性骨折。左膝9例,右膝7例。伤后至入院时间为2 h^3 d,平均10 h。X线片示关节面塌陷>2 mm;根据Schatzker分型标准:Ⅱ型6例,Ⅲ型10例;其中12例合并腓骨头骨折。观察手术切口长度、手术时间、术中出血量、术后切口愈合情况;X线片观察骨折愈合情况,测量胫骨平台内翻角和后倾角;CT复查关节面复位及再次塌陷情况。膝关节功能根据美国特种外科医院(HSS)评分标准进行评价。结果手术切口长度为7~10 cm,平均8.6 cm;手术时间35~55 min,平均46 min;术中出血量10~35 m L,平均28 m L。术后切口均Ⅰ期愈合。1例术后2个月发生克氏针退针导致的针尾刺激皮肤疼痛。术后15例获随访,随访时间8~21个月,平均13.5个月。X线片复查示骨折均愈合,愈合时间3~6个月,平均4.8个月;术后即刻及1年时胫骨平台内翻角、后倾角比较差异均无统计学意义(t=–1.500,P=0.156;t=–1.781,P=0.097)。CT复查示术后即刻关节面解剖复位率为93.8%(15/16);末次随访时测量关节再次塌陷高度为0.1~1.2 mm,平均0.36 mm。末次随访时膝关节功能按HSS评分标准,获优12例、良2例、可1例,优良率为93.3%。结论经后外侧入路有限切开、撬拨复位、简单内固定治疗胫骨后外侧平台塌陷性骨折具有损伤小、暴露充分、手术操作简便、膝关节功能恢复满意等优点,植骨支撑、简单内固定可防止术后关节面再塌陷。

Objective To explore the effectiveness of limited incision, poking reduction, and simple internal fixation in the treatment of collapsed fractures of the posterolateral tibial plateau. Methods Between October 2010 and January 2016, 16 patients with collapsed fractures of the posterolateral tibial plateau underwent posterolateral incision, poking reduction, and simple internal fixation. There were 10 males and 6 females with the age of 22-63 years （mean, 43.5 years）. The injury was caused by failing in 5 cases, traffic accident in 7 cases, and falling from height in 4 cases. All cases had closed fractures. The left knee was involved in 9 cases and the right knee in 7 cases. The injury-to-admission time was 2 hours to 3 days （mean, 10 hours）. X-ray films showed that the articular surface collapsing was more than 2 ram. According to Schatzker criteria, 6 cases were rated as type II and 10 cases as type III. Twelve cases had fracture of fibular head. The incision length, operation time, intraoperative blood loss, and incision healing were recorded; fracture healing was observed, and tibial plateau angle and posterior slope angle were measured on X-ray films;loss of articular surface reduction was observed by CT scan; and American Hospital for Special Surgery （HSS） score was used to evaluate the knee joint function. Results The incision length was 7-10 cm （mean, 8.6 cm）; operation time was 35- 55 minutes （mean, 46 minutes）; intraoperative blood loss was 10-35 mL （mean, 28 mL）. Primary healing of incision was obtained. Skin pain occurred in 1 case at 2 months because Kirschner wire retracted. Fifteen cases were followed up 8- 21 months （mean, 13.5 months）. The fracture healing time was from 3 to 6 months （mean, 4.8 months）. There was no significant difference in tibial plateau angle and posterior slope angle between at immediate after operation and at last follow-up （t=-1.500, P=0.156; t=-1.781, P=0.097）. The anatomic reduction rate of articular surface was 93.8% （15/16） at immediate after operation. At last follow-up, the recollapse height of articular surface was 0.1-1.2 mm （mean, 0.36 mm）. According to the HSS score system, the results were excellent in 12 cases, good in 2 cases, and fair in 1 case, and the excellent and good rate was 93.3%. Conclusion The limited incision by posterolateral approach, poking reduction, and simple internal fixation have the advantages of small injury, full exposure, and easy operation in the treatment of simple posterolateral tibial plateau fractures; bone graft support and simple internal fixation can prevent recollapse of the articular surface and achieve satisfactory knee function.